Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> - APPLICATION <br /> (For Non-Transferable,Revocable,'Land Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH-PERMIT <br /> 3 � l +•�-Ff C'a4w'��1930 - LIQUID WASTE 2-0 (--�0—Z2 <br /> Applicatio i reby d t .carry o" bu fness.l the'yrisdirtiona!area of the San Joaquin Local We th Distnc <br /> Business NamejDBA) y�7r - b Q`� Address "e "r' 4� <br /> z Owner `` © _Address <br /> Firm Partners, Addresses and Telephone Number <br /> CL <br /> Business-Telephone No. e ',l .f Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) Title : Date- <br /> Please check Applicable Category(1-7) and Fill in the Required Information , .r <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) } <br /> For July 1, June 30,19 _ Disposal Sites <br /> Description(Make/Yr., Color) s <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal.,Weights &Measures No. <br /> , F <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD #: <br /> For July 1, June 30,`19' <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored + <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location ' -Test Date/Time <br /> 4.A—SANITATION PERMIT 1.1 <br /> Job AddreWbocation c <br /> Owner Address <br /> CEfISEPTIC TANK ❑ CESSPOOL EACHING FIEL r -PIT ❑ PACKAGE PLANT '��) <br /> PERMANENT ❑ TEMPORARY .0-NEW ❑.REPAIR ❑ OTHER `��r <br /> 5. ❑ CHEMICAL TOILETS For July 1,1--June 30, 19 <br /> Type Construction + Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> S. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified - - <br /> Plant Location <br /> Plant Capacity No. Units Served P <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19— <br /> SIZE: <br /> 9 SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. f <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. : <br /> hereby certify that I have p. par th' is i atiora and that thb work will be done in accordance with San Joaquin County .; <br /> ordinances, state laws, and ul tr <br /> Health D <br /> Local in nd atl s o he San J aquLocHeaisict. <br /> r- - �. �._ .�, 1. _ <br /> .APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY _❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 8 Received By July 31 <br /> r I BILLING REMITTANCE $ REMIT <br /> BASE 3 EXPLANATION a AMOUNT DUE CHECKED <br /> r - -+- - DATE DATE REMITTED AMOUNT <br /> FEE' <br /> LESS <br /> PRORATION -' - • " <br /> PLUS r <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 1-7 17 <br /> Received by Date Receipt No. Permit No. I iss a_ncdd Date _ Mailed Delivered <br /> APPLICANT-RETURN ALL COPIES TO: ` ENVIRONMENTAL HEALTH PERMIT/SERVICES' 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />